Provider Demographics
NPI:1457355042
Name:HENGSTEBECK, ELIZABETH (DO)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:HENGSTEBECK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 SERVICE RD
Mailing Address - Street 2:A201
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-884-2976
Mailing Address - Fax:517-432-3928
Practice Address - Street 1:804 SERVICE RD
Practice Address - Street 2:A142
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-7015
Practice Address - Country:US
Practice Address - Phone:517-353-3050
Practice Address - Fax:517-432-3742
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8643207Q00000X
MI5101012728207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL47880YOtherMEDICARE PART B, PTAN
MI1457355042Medicaid
FL99388OtherMEDICARE PART B, GROUP PTAN
FL265730900Medicaid
FL47880YOtherMEDICARE PART B, PTAN
FL265730900Medicaid
FL99388OtherMEDICARE PART B, GROUP PTAN